Questions 9

ATI RN

ATI RN Test Bank

ATI Fluid Electrolyte and Acid-Base Regulation Questions

Question 1 of 5

You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)?

Correct Answer: A

Rationale: The correct answer is A: Increased serum sodium. High serum sodium levels trigger the release of antidiuretic hormone (ADH) from the pituitary gland to help retain water in the body and maintain fluid balance. This is a physiological response to prevent further dehydration. Decreased serum potassium (choice B), decreased hemoglobin (choice C), and increased platelets (choice D) do not directly stimulate the release of ADH. Hence, they are incorrect choices in this scenario.

Question 2 of 5

You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?

Correct Answer: B

Rationale: The correct answer is B: Hypocalcemia. Following a thyroidectomy, there is a risk of damaging the parathyroid glands, leading to hypocalcemia. Symptoms such as tingling in lips and fingers, muscle spasms, and increased muscle tone are classic signs of hypocalcemia. The initial concern should be hypocalcemia due to its potential to cause serious complications such as tetany and laryngospasm. Options A, C, and D are incorrect as they do not align with the symptoms described. Hypophosphatemia may present with weakness and respiratory failure, hypermagnesemia with hypotension and respiratory depression, and hyperkalemia with muscle weakness and cardiac arrhythmias.

Question 3 of 5

While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?

Correct Answer: A

Rationale: The correct answer is A: Grade 3 phlebitis at IV site. This finding indicates inflammation of the vein due to irritants from the IV catheter, supported by red streak and palpable cord. Grade 3 phlebitis involves pain, redness, swelling, and palpable venous cord. Infection (B) typically presents with signs like pus, warmth, and fever. Thrombosis (C) involves a blood clot, not a palpable cord. Infiltration (D) is leakage of IV fluid into surrounding tissues, not related to palpable cord and red streak.

Question 4 of 5

. You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to as

Correct Answer: D

Rationale: The correct answer is D: Fluid volume status. Assessment of specific gravity helps to determine the concentration of solutes in the urine, indicating the degree of hydration or dehydration. In SIADH, there is water retention leading to diluted urine, resulting in low specific gravity. Monitoring specific gravity every 4 hours is crucial in assessing the patient's fluid volume status and response to treatment. A: Nutritional status is not directly assessed by specific gravity. B: Potassium balance is not directly assessed by specific gravity. C: Calcium balance is not directly assessed by specific gravity.

Question 5 of 5

A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next?

Correct Answer: A

Rationale: The correct answer is A: Assess clients rate, rhythm, and depth of respiration. The arterial blood gas values indicate a respiratory acidosis due to low pH and low PaCO2. The nurse should assess the respiratory status to determine if the client is hypoventilating, which is causing the retention of CO2 and subsequent acidosis. Assessing the rate, rhythm, and depth of respiration will help determine if the client requires immediate intervention such as oxygen therapy, mechanical ventilation, or respiratory treatment. Choice B is incorrect because measuring pulse and blood pressure does not directly address the underlying cause of the acid-base imbalance. Choice C is incorrect as the nurse should take immediate action to address the imbalance rather than passively monitoring. Choice D is incorrect as immediate intervention is needed to address the respiratory acidosis.

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